Related Content

What Are Marketplace Deductibles, Coinsurance, and Copayments?

TMA’s Education Campaign Returns With Answers to Questions

About the ACA Marketplace

Aug. 13, 2014

Health
insurance has its own language: deductibles, coinsurance, and copayments, or copays.
These are costs you as a patient have to pay — in addition to your premiums
that you’ve already been paying — when you seek health care. Health insurance
policies offered on the Affordable Care Act’s (ACA’s) health insurance
marketplace are just like other health insurance policies.

Deductibles,
coinsurance, and copayments basically describe the costs you share with the
insurance company and pay to physicians and other providers for your health
care.

Let’s start with the deductible, because that’s the amount you typically have
to pay first before your insurance starts to cover much of your health care
costs. Say you have a $1,000 deductible for the year. That means you’re
responsible for paying the first $1,000 of your medical expenses before the
insurance company helps pick up the rest. You might “meet that deductible” (pay
that part you’re responsible for) in one hospital stay, or you could meet it
throughout the year in multiple doctor visits. Because your insurance policy
covers one year at a time, you would meet that deductible once a year, and it
resets when you renew your insurance. Depending on your plan, once you’ve met
your deductible, your insurance will start to cover a greater portion of your
medical expenses.

Which brings us to the coinsurance, which is different. Instead of a fixed
amount, like the deductible, the coinsurance is the percentage of a particular
medical cost that you are responsible for. Let’s say it costs $100 for an x-ray
and your co-insurance is 20 percent. You would pay $20 of that cost, and your
insurance would pay the rest, $80. Depending on your plan, that $20 could go
towards your deductible, or sometimes the coinsurance won’t kick in until after
you’ve met your entire deductible. And the coinsurance amount can vary
depending on whether you receive medical services in or outside of your health
plan’s network.

Lastly, each time you visit the doctor, you’ll typically pay what’s called a copayment
or “copay.” It’s usually a small fixed fee, like $25, that you pay up front at
each visit, not something you split with your insurance plan. It can also vary
depending on the medical service.

But marketplace plans must cover certain preventive services, like screenings
and immunizations, without making you meet your deductible, or pay coinsurance
or copayments. That’s if you get those services in-network.

And keep in mind that the health care law puts a limit on your out-of-pocket
medical expenses each year. Once you reach that limit, your insurance usually
covers 100 percent of your medical expenses.

TMA is the largest state medical society in the nation,
representing more than 47,000 physician and medical student members. It is
located in Austin and has 112 component county medical societies around the
state. TMA’s key objective since 1853 is to improve the health of all Texans.